A study of clinical profile of patients with acute kidney injury in a tertiary care centre

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1 Maulita P Kapadia et al /International Journal of Advances in Scientific Research 2016; 2(08): International Journal of Advances in Scientific Research ISSN: (Online) Journal DOI: /ijasr Research Article A study of clinical profile of patients with acute kidney injury in a tertiary care centre Maulita P Kapadia *1, Panna K Kamdar 2 and P. R. Jha 1 1 Department of Medicine, Govt. Medical College, Bhavnagar, Gujarat (India) 2 Department of biochemistry, Govt. Medical College, Bhavnagar , Gujarat (India) *Correspondence Info: Dr. Maulita P Kapadia 3 rd year resident in Department of Medicine, Govt. Medical College, Bhavnagar Gujarat (India) drmaulitakapadia@gmail.com Abstract Objectives: The objectives of the study are to study etiology, manifestations and outcome of acute kidney disease. Method: In present study, patients with acute kidney disease admitted to Sir T Hospital, Govt. Medical College Bhavnagar between June 2013 and July 2014 are studied with a detailed history, general physical examination, and systemic examination and investigated as per the proforma. Data collected, analysed and the test of significance was calculated by chi square, student s t test. Results and conclusion: A prospective study of 100 cases of acute kidney injury admitted to Sir T Hospital Bhavnagar between June 2013 and July 2014 is done. Diagnosis of the patients is based on the clinical and laboratory evidence of elevated blood urea and serum creatinine. This study showed male to female ratio of 2.7:1. Maximum incidence is seen between years. The study showed various etiological factors associated with acute kidney injury like malaria, snake bite, septicaemia, heart failure, cirrhosis, drug nephrotoxicity and acute gastroenteritis. 8 patients had obstructive uropathy. Common symptoms are oliguria and vomiting, other clinical features are fever, jaundice, loose stool and peripheral edema. However, septicaemia is the predominant cause of acute kidney injury in our study. Out of 100 cases, 93% patients survived and 7% expired. 83% patients are on conservative management and 17% underwent hemodialysis. Out of 100 cases, 51 patients are having associated illness which made them prone to develop AKI. Mortality is also seen more among this group. Most common comorbid illnesses are DM, HTN and IHD. Keywords: Acute kidney injury, hemodialysis. 1. Introduction Acute Kidney Injury is a new consensus term, encompassing a range of kidney diseases of acute onset. Two trials, namely program to improve care in acute renal disease (PICARD) and Beginning & Ending Supportive Therapy (BEST) for the kidney confirmed that AKI is a significant contributor toward mortality and morbidity. [1] RIFLE classification scheme and acute kidney injury network (AKIN) classification scheme have been proposed to achieve early diagnosis of AKI. Reliable and comparable data about the clinical spectrum of AKI is necessary for optimizing the management. However, minimal data is currently available from India using standardized criteria. [1] In India, Acute Kidney Injury constitutes 1.5% of all general hospital admissions, of which 60% are due to medical causes. 2 the most common causes of AKI are: acute diarrhoeal diseases, sepsis, infection (malaria, UTI, pneumonia, viral hepatitis), snake bite, cardiac failure, diabetes mellitus, nephrotoxic drug use, malignancy, SLE, hypertension etc. major surgery like exploratory laparotomy, whipple s procedure etc are also an important cause of AKI. Advanced age, liver diseases, underlying comorbid illness (DM, HTN, IHD, COPD, cirrhosis) have been implicated as risk factor for the development of AKI. [3] The burden of AKI may be most significant in developing countries with limited resources for the care of these patients once the disease progresses to kidney failure necessitating RRT. Addressing the unique circumstances and needs of developing countries, especially in the detection of AKI in its early and potentially reversible stages to prevent its progression to kidney failure requiring dialysis, is of paramount importance.aki is amenable to early detection and potential prevention. There is considerable variability in practice to prevent, diagnose, treat, and achieve outcomes of AKI. [2]

2 Maulita P Kapadia et al / Reference ranges in hospital population 161 We retrospectively evaluated patients with AKI, using the RIFLE criteria, to answer questions regarding most susceptible population, etiology, role of dialysis, outcomes. 2. Materials and methods This is a study of 100 patients with acute kidney disease admitted to Sir T Hospital, Govt. Medical College Bhavnagar between June 2013 to July Selection criteria: 2.1 Inclusion criteria: 100 patients of acute kidney disease admitted in Sir T hospital Bhavnagar. 2.2 Exclusion criteria: 1. Patients of chronic renal failure. 2. Patients who do not give consent for study. 3. Patients aged below 13 years. Patients included were studied with a detailed history, general physical examination, and systemic examination and investigated. Data analysed and conclusions drawn about age and sex distribution, etiology of AKI, classification of AKI and comparison of GFR, creatinine and urea on admission and discharge. The test of significance was calculated by chi square, student s t test. 3. Results A total number of 100 cases with acute kidney disease, admitted to Sir T Hospital, who met the inclusion criteria, are studied. Out of 100 cases studied, 73 patients are males and 27 are females. Table 1: Age distribution Age No. of Patients Percentage < % % % % % > % Table 2: Distribution of patients according to clinical symptoms Clinical symptoms No. of patients Oliguria 63% Loose stool 18% Vomiting 81% Fever 61% Edema 37% Jaundice 5% Dyspnoea 13% Altered Sensorium 8% Figure 1: Comparison of GFR on admission and on discharge/ expired In this study, GFR on admission was found to be ml/min/1.73m 2 and on discharge ml/min/1.73m 2 with P-value of <

3 Maulita P Kapadia et al / Reference ranges in hospital population 162 Figure 2: Comparison of serum urea on admission and on discharge or expired Figure 3: Comparison of serum creatinine on admission and on discharge or expired Outcome: Out of 100 cases studied, 93 patients survived, mortality was 7 %. Comorbidity: In our study, incidence of AKI was found to be more common in patients with comorbid illness. Out of 100 patients studied, 51 patients were having associated diseases (DM, HTN, IHD, CCF, COPD, PLHA or cirrhosis) Association of comorbidity with Outcome: Mortality was seen more among patients with comorbidity suggestive of poor prognosis. Out of 7 patients who expired in the study, 4 were having comorbidity associated with it. 4. Discussion The observations made in 100 cases of AKI admitted to Sir T Hospital Bhavnagar from June 2013 to July 2014 are discussed and compared with other studies. The study revealed that mean age of patients were on lower side than western studies but comparable with most of Indian studies.

4 Maulita P Kapadia et al / Reference ranges in hospital population 163 1) Age and sex: In present study, age group of patients with AKI ranged from 20 to 80 years with mean age of 44.5 years, out of which 73% are males and 27% are females. The result are comparable with other studies done by Mataloun et al[35], Olaga B et al[36] and Picard[37] as tabulated below: Table 3: Comparison of Age and sex Study Male Female Mean age group (years) Picard study[37] 59% 41% 59.5 Mataloun[35] 46.2% 53.8% 55.3 Olaga B[36] 60% 40% 69.6 Present study 73% 27% 44.5 In other study done by Shah et al[38] found that maximum numbers of patients are between years of age group with mean age of 38.4 years which is again comparable with present study. 2) Clinical symptoms: A study of clinical presentation of patients was done. We noted that vomiting and oliguria were most common symptoms comprising of 81% and 63% respectively. This finding is comparable with other studies done by Liano and Pascual [42] and Eswarappa M [1]. Table 4: Comparison of Clinical symptoms Clinical symptoms Present study Eswarappa M[1] Liano and Pascual [42] Vomiting 81% 86% Oliguria 63% 67% 80% Fever 61% 52% - Edema 37% 28% - Jaundice 5% 21% - Breathlessness 13% - - Altered sensorium 8% - - Oliguria is also found to be the most common presentation in other studies done by Bagshaw et al [39] and Romao junior E et al [40]. 3) Classification of AKI: In present study, acute kidney injury is classified as prerenal, renal and postrenal according to the etiology. Another classification is on the based on RIFLE criteria. The observations are comparable with studies done by Balushi et al [41] and Liano and Pascual [42]. Table 5: The comparison is tabulated below AKI Balushi et al[41] Liano and Pascual [42] Kumar et al[33] Present study Prerenal 50.9% 21% 20.6% 26% Renal 44.5% 45% 69.6% 66% Postrenal 4.6% 10% 9.8% 8% Most common cause of AKI was found to be renal/ intrinsic. Similar results were found in other studies done by Brivet et al [43]. RIFLE classification: In present study, 58% patients were in risk group, 23% in injury group and 17% in failure group which is comparable with other studies done by Eswarappa M [1], Balushi et al [41] and Mohan et al [44]. Table 6: RIFLE classification Classification Risk Injury Failure Mohan G[44] 24% 34% 42% Eswarappa M[1] 24.4% 37% 35% Balushi et al[41] 19% 35% 46% Present study 58% 17% 23% 4) Etiology of Aki: In the present study, we have also compared the etiology of AKI. In our study we have noted that most common cause of AKI was septicemia contributing to 44% of cases whereas nephrotoxicity was seen in 6% and malaria in 9% of cases. Comparison is also made with other studies done by Eswarappa M [1] and Shah et al [38] Comparison is tabulated below.

5 Maulita P Kapadia et al / Reference ranges in hospital population 164 Table 7: Etiology of Aki Etiology Present study Eswarappa M[1] Kumar et al[33] Malaria 9% 6.4% 0.9% Septicemia 48% 38.6% 32.4% AGE 11% 10.4% 20.6% Snakebite 2% 2.6% 4% CCF 7% 6.8% - Cirrhosis 7% 6.0% - Nephrotoxicity 6% - - Obstetric causes 2% - 4.9% 5) Source of sepsis: Table 8: Comparison with other studies Source of sepsis Present study Shah et al[38] Bagshaw et al[39] Thoracic Intra-abdominal Endovascular Urogenital Skin/soft tissue/bone other ) Comparison of clinical profile of patients Table 9: Comparison of clinical profile of patients Parameters Present study Shah et al[38] Bagshaw et al[39] Mean [SD] P-value Mean [SD] P-value Mean[SD] Temperature(F) 99.33[0.97] < [1.6] Pulse(/min) 96.07[12.92] < [13.88] [21] SBP(mm of Hg) [16.37] < [22.48] < [27] DBP(mm of Hg) 81.96[7.35] < [16.59] RR(/min) 19.01[2.73] < [3.06] [6.5] Hb (g %) 10.35[2.02] < [2.42] TC(x103 /cumm) 19.52[9.073] < [10.7] Urea(mg/dl) [66.64] < [74.20] Creatinine(mg/dl) 3.64[3.1] < [3.41] ) Association of presence of co morbid illness with AKI outcome and prognosis Table 10: Comparison is tabulated below Study No. of patients with co-morbidity Prakash et al [22] 52% Eswarappa M [1] 61.4% Kumar et al[33] 33.36% Present study 51% Table 11: Co morbid illness found in patients Co morbid illness Picard[37] Prakash et al [22] Balushi et al [41] Kumar et al[33] Present study DM 29% 28.3% 50.9% 1.9% 41.82% HTN 37% 34.7% 53.7% 3.9% 24.09% IHD % 50.9% 6.9% 16.36% Cirrhosis 21% % COPD 11.9% 5.45% 8) Management and outcome of disease In present study of 100 cases 93% patients survived and about 7 percent patients expired. Among 100 cases, 83% patients are managed conservatively and 17% patients underwent hemodialysis. Out of 83% patients managed conservatively 2% died and 17% who underwent hemodialysis 5% died. Good results are obtained with patients on conservative management. Conservative management include prompt diagnosis and initiation of treatment. Patients who died were having septicaemia and associated complications. Comparison with other studies is tabulated below:

6 Maulita P Kapadia et al / Reference ranges in hospital population 165 Table 12: Management and outcome of disease Study Conservative management Hemodialysis Eswarappa [1] 62.8% 37.2%% Liano and Pascual [42] 64% 36% Present study 83% 17% The major risk factor affecting prognosis of the patients were presence of multi-organ failure, high baseline serum creatinine level and complication developed during the course of illness. In the present study, mortality is seen among the patients who had high serum creatinine on admission as compared to survived patients. Prognosis is also found to be poor in patients with co morbid illnesses. Out of 51 patients with co morbidity, mortality is 57% which justifies poor prognosis of patients who develop AKI in presence of co morbid illness. Thus age more than 65 years and presence of co morbidity are poor prognostic indicators of AKI. 4. Conclusions In this study 100 patients admitted between June 2013 to July 2014 at Sir T hospital, Bhavnagar are observed prospectively. The clinical feature and various etiology of acute kidney injury are studied. It is observed that clinical features are almost in accordance with studies conducted earlier. Oliguria and vomiting are the predominant symptom in acute kidney injury. However, we observed that septicaemia is the predominant cause of acute kidney injury and these patients recovered with conservative management and very few needed hemodialysis. Other causes of acute kidney injury were similar to other studies like drug nephrotoxicity, acute gastroenteritis and septicaemia. About 93% patients survived. 83% patients were on conservative treatment and 17% patients underwent hemodialysis. We observed that early diagnosis and intervention were probably responsible for good survival rate. References [1] Eswarappa M, Gireesh M S, Ravi V, Kumar D, Dev G. Spectrum of acute kidney injury in critically ill patients: A single centre study from South India. Indian J Nephrol 2014 Sep-Oct; 24(5): [2] Dr Naveen T. M. U. The Study of Spectrum of Acute Renal Failure in Kims Hubli [3] Thadani R, Pascaul M, Bonvette VB, Acute Renal Failure. The New England Journal of Medicine 1996: 30; [4] Eknoyan G, Emergency of concept of acute renal failure. American Journal of Nephrology, 2002: 22; [5] Bywaters EGL, Beall D. Crush injuries with impairment of renal function. BMJ 1947; 1: [6] Kellum JA, Levin N, Bouman C, et al. developing a consensus classification system for acute renal failure. Curr Opin Crit Care 2002; 8: [7] Harrison s Principle of Internal Medicine 18 th edition Vol 2 : 2293 [8] Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007; 11: R31. [9] Gray s Anatomy [10] KDIGO Kidney international supplements, Journal of the international society of Nephrology. 2012: 2; [11] Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. JAMA. 2003; 289: [12] USRDS Annual Data Report. Atlas of endstage renal disease in the United States: incidence and prevalence. Am J Kidney Dis. 2003; 41:S41 S56. [13] Olson JL. Hypertension: essential and secondary forms. In: Jennette JC, Olson JL, Schwartz MM, Silva FG, eds. Heptinstall s Pathology of the Kidney, 2, ed.5. Philadelphia: Lippincott-Raven; 1998: [14] Bidani AK, Griffin KA. Long-term renal consequences of hypertension for normal and diseased kidneys. Curr Opin Nephrol Hypertens. 2002; 11: [15] Navar LG. Renal autoregulation: perspectives from whole kidney and single nephron studies. Am J Physiol. 1978; 234:F357 F370. [16] Karlsen FM, Andersen CB, Leyssac PP, Holstein- Rathlou N-H. Dynamic autoregulation and renal injury in Dahl rats. Hypertens. 1997; 30: [17] Long DA, Price KL, Herrera-Acosta J, Johnson RJ. How does angiotensin II cause renal injury? Hypertens. 2004; 43: [18] Diabetes Mellitus- vascular mechanism. Am J Physiol. 2004; 286 F8-F15. [19] Dalla Vestra M, Saller A, Mauer M, et al. Role of mesangial expansion in the pathogenesis of diabetic nephropathy. J Nephrol 2001; 14 Suppl 4:S51-S57. [20] Abbate M, Zoja C, Corna D, Capitanio M, Bertani T, Remuzzi G. In progressive nephropathies, overload of tubular cells with filtered proteins translates glomerular permeability dysfunction into

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